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Electronic health records (EHR) are important components of the healthcare system that allow patients’ information to be available for all pertinent healthcare providers in a systemized, easily accessible location. EHRs are used to support care that is focused on the patient and improve the quality and safety of treatments. It is for this reason that EHRs are a nationally-funded agenda in this country (Nelson & Staggers, 2018). As the healthcare industry evolves and changes, it is necessary that the health informatics systems remain streamline as well. Terminology is a representation of concepts in a specific domain of interest and is vital for meaningful use of EHRs (Nelson & Staggers, 2018). Nelson & Staggers (2018) define meaningful use as sets of specific objectives that must be achieved in order to qualify for federal incentive payments. Healthcare providers must use certified electronic health record technology so that specific criteria can be measured and captured (Nelson & Staggers, 2018). Point-of-care standardized terminologies are critical components of EHRs that capture and represent various components such as assessment, service and outcome data and enable meaningful translation of care concepts to data (Martin, Monsen, & Bowles, 2011). The American Nurses Association recognizes 12 healthcare terminologies appropriate for use in nursing, seven of which are designed specifically for nursing and are used in practice today (Nelson & Staggers, 2018). Among this list are the Omaha System and the Clinical Care Classification System (CCC) which will be further explored and compared throughout the remainder of the paper.
The Omaha System was developed in the 1970s among researchers and practitioners from different disciplines to deliver a computerized information management system that focused on patients receiving services in a home healthcare setting (Martin et al., 2011). According to Martin et al. (2011), the Omaha System is a multidimensional computer system used by providers to document and collect information about patient care across the continuum of care. This system has significant meaningful use it enhances practice and documentation in a user-friendly manner that is open to the public with no additional fees (Martin et al., 2011). Lee (2016) stated that the Omaha System data consists of modified descriptions related to patient care that can reveal changes in a client’s status over time. In 2005, an updated version of the Omaha System was created and consists of three schemes: problem classification, intervention and the problem rating scale for outcomes (Nelson & Staggers, 2018).
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The problem classification, or assessment scheme consists of 42 problem statements or areas of focus related to the patient. These 42 problem states are then connected to two modifiers related to the potential of health promotion and health problems (Nelson & Staggers, 2018). The problems are placed in one of four domains, including environmental, psychosocial, physiological and health-related behaviors. Examples from each domain include income, grief, pain and nutrition, respectively. The problem classification scheme is specific to each patient and provides a foundation for providers to develop a care plan based on their initial assessment.
Once a problem has been identified, the intervention phase enables providers to choose patient-specific information and interventions from a selection of 75 interventions. Once an intervention is completed, providers choose four action categories consisting of teaching, treatments/procedures, case management and surveillance (Nelson & Staggers, 2018). This phase enables providers to develop an individualized care plan for patients to include goals, such as medical coordination, access to durable medical equipment and occupational therapy care. Regardless of the ease or complexity of the intervention, the intervention scheme focuses on health prevention and improvement and ensures that practice is communicated effectively between members of the healthcare team.
The final scheme of the Omaha System is the problem rating scale. This scale measures outcomes using a Likert-style measurement scale that ranges from 1-5 in areas of knowledge, behavior and systems status concepts (Martin et al., 2011). The scoring system provides a baseline evaluation that can be used to deliver useful information. This information can then be used to improve quality and evaluate patient progress while receiving services. By evaluating patients at different time intervals during their care, providers are able to reevaluate and reassess patients based on their scoring and adjust their plan of care if warranted.
The Omaha System has predetermined sets of information that are available for program evaluation, research and education. The ease of use of the system alone increases interoperability and appeals to many healthcare systems. The Minnesota Omaha Systems Users Group presents a case example using the Omaha System took place in Minnesota and was used to engage seniors in health promotion activities and evaluate interventions at a community level to address chronic health issues (as cited in Martin et al., 2011). Within a blood pressure clinic public health nurses used a standardized protocol that addressed four problems including circulation, medication regime, communication with providers and mental health. After data was analyzed and the most common problems were identified, local physicians were made aware of the information. By identifying these problems through their assessments, interventions were tailored to meet the needs of the patient including blood pressure self-care and changes in medication regime. By using the Omaha System, an interdisciplinary approach is used to improve patient-centered clinical practice and enables meaningful use of data to improve quality of care.
Clinical Care Classification System
Similar to the Omaha System, the Clinical Care Classification System (CCC) is a standardized terminology system relevant to nursing practice. The CCC was developed in 1991 as the Home Health Care Classification System and consisted of diagnoses and interventions encompassed within 21 care components. These components combine nursing practice with similar patterns in four health pattern domains including functional, health behavioral, physiological and psychological (Nelson & Staggers, 2018). The CCC contains 182 nursing diagnosis that is enhanced by three modifiers: improved, stabilized or deteriorated to document expected and actual outcomes. There are also 198 nursing interventions that are enhanced by four actions, including assess/monitor, care/perform, teach/instruct and manage/refer (Feng & Chang, 2015). A total of 528 nursing outcomes are available within the CCC that enables users to relay care. There is a coding structure within the system that consists of five alphanumeric digits. The first digit signifies a care component, the second and third represent the category of nursing diagnosis or intervention, the fourth is a subcategory of diagnosis and intervention and the fifth digit is the expected outcome or action taken (Feng & Chang, 2015). The codes are used to link to each other and are mapped to other terminology such as SNOMED. This system allows the nursing diagnosis to be made based on a thorough evaluation of symptoms and assessment of nursing interventions.
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Najafi, Rassoulzadeh and Rassouli (2018) provide an example of the use of the CCC when caring for a 65-year-old man in the intensive care unit status post coronary artery bypass graft surgery. The following information was provided about the patient: intubated, normal sinus rhythm on the monitor, central line in place, the basic metabolic panel sent, midline chest dressing clean and dry, area of redness on buttocks, blood sugars elevated and an increase in thick secretions. Using the CCC system, diagnoses that were extracted included electrolyte imbalance, impaired skin integrity, changes in blood pressure and disorders in clearing the airway. Nursing interventions that resulted from the report included ventilator care, dressing change and oxygen therapy. Using this information, a series of expected outcomes are developed for the patient to improve or stabilize the patient’s condition. This case example highlights how point of care documentation can facilitate clinical decision making within the healthcare setting. By utilizing this system that collects all of the components of the nursing process, holistic patient care is consistent and improved and care priorities are recognized.
Comparison of Terminologies
Both the Omaha System and CCC are examples of point of care systems that focus on documentation allowing for identification and support of nursing assessment, interventions and outcomes. Both systems charge no fee for use and prove to be useful tools within EHRs for recognizing and coding problems as well as interventions. A review of the literature illustrates how both systems are essential components of nursing research, education and practice within a variety of healthcare settings. Despite the similarities mentioned throughout, there are some differences between the two systems. While both systems are recognized as nursing practice terminologies, CCC is specific to elements surrounding direct nursing care while the Omaha System is effective in communicating care between multidisciplinary health care providers. Other differences between the two systems include the fact that the Omaha System incorporates family and community into the process while the CCC is focused solely on the individual. While the Omaha System uses a problem rating scale for outcomes, the CCC does not have any rating scales but rather groups nursing practices with similar patterns for simple classification of nursing diagnosis, interventions, and actions.
EHR’s and health information technologies are an integral component of the healthcare system that improves the quality and efficiency of care delivered in this country every day. The use of standardized terminology systems enables interoperability and provide consistent quality care for patients throughout the continuum of care. Standardized healthcare terminologies are components of EHR’s that are essential to facilitate effective communication and data collection across systems and disciplines (Nelson & Staggers, 2018). The implementation of such systems, like the Omaha and the CCC, are key to improving practitioner workflow, improving patient outcomes and providing a meaningful translation of care.
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